Predictors and effects of community sanitation for control of Neglected Tropical Diseases in Amhara Region, Ethiopia Open Access

Oswald, William Edward (2015)

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Sanitation, or safe disposal of human excreta, is fundamental to a hygienic living environment and to public health. Neglected Tropical Diseases, like trachoma and soil-transmitted helminth (STH) infections, occur under unhygienic conditions and predominantly affect children. Sub-Saharan Africa suffers from low levels of sanitation access, and heterogeneity in sanitation access also exists within countries in this area. Few studies have examined the relationship between these diseases and sanitation access as a community measure or reasons for geographic heterogeneity in community sanitation. This dissertation examined these questions using data combined from five surveys conducted across Amhara Region, Ethiopia between 2011-2014 by the Amhara Regional Health Bureau and The Carter Center's Trachoma Control Program. The first two studies aimed to estimate the effect of community sanitation on prevalence among children of active trachoma and infection with three STH (Ascaris lumbricoides, Trichuris trichiura, hookworm). Multilevel analyses were conducted using generalized linear mixed models, accounting for complex survey design. The first study found that increased community sanitation was associated with decreased prevalence odds of active trachoma among children, aged 1 to 9 years, following 5 years of trachoma-control activities. The second study found no evidence of a protective association of increased community sanitation with prevalence of STH infection among children, aged 6 to 15 years. Hookworm prevalence was not associated with community sanitation. T. trichiura and A. lumbricoides prevalence was higher in communities with higher sanitation. Association of community sanitation with A. lumbricoides prevalence depended on household sanitation. The third study aimed to develop and validate a model to predict low community sanitation. Logistic regression was used with remote-sensing and other data on environmental and social conditions. The selected model predicted low community sanitation with reasonable discrimination and was used to generate a risk map of poor community sanitation for Amhara Region. These studies demonstrate the need for increased community sanitation to reduce trachoma prevalence and further research to clarify the role of community sanitation in preventing STH infections. Predictive modeling using environmental and social conditions can assist health and sanitation programs to identify areas that need additional or alternate sanitation interventions.

Table of Contents

Chapter 1 - Introduction. 1

Aims of Dissertation. 4

Chapter 2 - Trachoma. 5

Global Burden of Disease. 5

Clinical Features. 6

Detection of Disease and Infection. 7

Transmission. 10

Control and Prevention. 11

Chapter 3 - Soil-transmitted Helminth Infections. 20

Occurrence. 20

Identification and Clinical Signs. 20

Etiology and Epidemiology. 22

Lifecycle and Transmission. 22

Control and Prevention. 25

Chapter 4 - Sanitation. 29

Sanitation and Health. 30

Community Sanitation Coverage and Household Sanitation Access. 32

Community-based Sanitation Interventions. 33

Environmental Conditions and Community Sanitation. 34

Chapter 5 - Association of Community Sanitation Usage with Active Trachoma among Children in Amhara Region, Ethiopia. 38

Chapter 6 - Association of Community Sanitation Usage with Soil-Transmitted Helminth Infections among School-aged Children in Amhara Region, Ethiopia. 58

Chapter 7 - Prediction of Low Community Latrine Coverage using Environmental and Social Factors in Amhara Region, Ethiopia. 85

Chapter 8 - Conclusion. 117

References. 126

Appendix 1 - IRB Documentation. 147

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